Selection of severely head injured patients for mild hypothermia therapy

1998 ◽  
Vol 89 (2) ◽  
pp. 206-211 ◽  
Author(s):  
Tadahiko Shiozaki ◽  
Hisashi Sugimoto ◽  
Mamoru Taneda ◽  
Jun Oda ◽  
Hiroshi Tanaka ◽  
...  
Keyword(s):  
Functional Recovery ◽  
Mild Hypothermia ◽  
High Dose ◽  
Midline Shift ◽  
Cerebral Lesions ◽  
Content Type ◽  
Head Injured ◽  
Gcs Score ◽  
Injured Patients ◽  
Fine Print

Object. The authors have analyzed the efficacy of inducing mild hypothermia (34°C) in 62 severely head injured patients to control fulminant intracranial hypertension. Methods. All 62 patients fulfilled the following criteria: 1) persistent intracranial pressure (ICP) greater than 20 mm Hg despite fluid restriction, hyperventilation, and high-dose barbiturate therapy; 2) an ICP lower than the mean arterial pressure; and 3) a Glasgow Coma Scale (GCS) score of 8 or less on admission. The patients were divided into three groups based on computerized tomography findings: extracerebral hematoma (34 patients with subdural and/or epidural hematoma), focal cerebral lesion (20 patients with localized brain contusion and/or intracerebral hematoma), and diffuse swelling (eight patients with no focal mass lesion). Mild hypothermia prevented ICP elevation in 35 (56.5%) of the 62 patients whose ICP was greater than 20 mm Hg despite conventional therapies. Among those 35 patients whose ICP was controlled by mild hypothermia, 12 (34.3%) achieved functional recovery (good outcome or moderate disability). However, functional recovery was observed in only five (10.9%) of the 46 patients whose ICP was greater than 40 mm Hg after conventional therapies. Of 40 patients with an admission GCS score of 5 to 8, there were 11 (27.5%) who achieved functional recovery. On the contrary, mild hypothermia was not effective in 22 patients with an admission GCS score of 3 or 4. In the patients with focal cerebral lesions, ICP was controlled by mild hypothermia in 17 patients (85%) and patient outcome was intimately related to the extent of the damage. Among 18 patients with extracerebral hematoma who had a midline shift of 9 to 12 mm, raised ICP could be successfully controlled by mild hypothermia in 16 patients (88.9%) and three (16.7%) achieved functional recovery. However, ICP could not be controlled in patients with extracerebral hematoma who had a midline shift of 13 mm or more. In patients with diffuse swelling, ICP elevation could not be prevented at all by mild hypothermia. Conclusions. The authors conclude that mild hypothermia is effective for preventing ICP elevation in patients without diffuse brain swelling in whom ICP remains higher than 20 mm Hg but less than 40 mm Hg after conventional therapies.

Little benefit from mild hypothermia therapy for severely head injured patients with low intracranial pressure

1999 ◽  
Vol 91 (2) ◽  
pp. 185-191 ◽  
Author(s):  
Tadahiko Shiozaki ◽  
Amami Kato ◽  
Mamoru Taneda ◽  
Toshiaki Hayakata ◽  
Naoyuki Hashiguchi ◽  
...  
Keyword(s):  
Intracranial Pressure ◽  
Mild Hypothermia ◽  
Neurological Status ◽  
High Dose ◽  
Fluid Restriction ◽  
Content Type ◽  
Head Injured ◽  
Factor Α ◽  
Injured Patients ◽  
Fine Print

Object. This study was performed to determine whether mild hypothermia therapy is essential for the treatment of severely head injured patients in whom intracranial pressure (ICP) can be maintained below 20 mm Hg by using conventional therapies.Methods. Sixteen consecutive severely head injured patients fulfilled the following criteria: the patient's ICP was maintained below 20 mm Hg by using fluid restriction, hyperventilation, and high-dose barbiturate therapy; and the patient had a Glasgow Coma Scale score of 8 or less on admission. After conventional therapies had been applied, the patients were divided randomly into two groups: the mild hypothermia group (HT group; eight patients) and the normothermia group (NT group; eight patients). The HT group received mild hypothermia (intracranial temperature 34°C) therapy for 48 hours followed by rewarming at 1°C per day for 3 days, whereas the NT group received normothermia (intracranial temperature 37°C) therapy for 5 days. Specimens of cerebrospinal fluid (CSF) taken from an intraventricular catheter every 24 hours were analyzed for the presence of excitatory amino acids ([EAAs] glutamate, aspartate, and glycine) and cytokines (tumor necrosis factor—α, interleukin [IL]-1β, IL-6, IL-8, and IL-10). The two groups did not differ significantly in patient age, neurological status, or level of ICP. There were no significant differences in daily changes in CSF concentrations of EAAs and cytokines between the two groups. The incidence of pneumonia was slightly higher in the HT group compared with the NT group (p = 0.059). The incidence of diabetes insipidus associated with hypernatremia was significantly higher in the HT group compared with that in the NT group (p < 0.01). The two groups did not differ with respect to their clinical outcomes.Conclusions. The authors recommend normothermia therapy for the treatment of severely head injured patients in whom ICP can be maintained at lower than 20 mm Hg by using conventional therapies, because mild hypothermia therapy does not convey any advantage over normothermia therapy in such patients.

Role of intracranial pressure monitoring in severely head-injured patients without signs of intracranial hypertension on initial computerized tomography

1994 ◽  
Vol 80 (1) ◽  
pp. 46-50 ◽  
Author(s):  
Michael G. O'Sullivan ◽  
Patrick F. Statham ◽  
Patricia A. Jones ◽  
J. Douglas Miller ◽  
N. Mark Dearden ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Ct Scan ◽  
Intracranial Hypertension ◽  
Mass Lesion ◽  
Midline Shift ◽  
Pressure Monitoring ◽  
Content Type ◽  
Head Injured ◽  
Injured Patients ◽  
Fine Print

✓ Previous studies have suggested that only a small proportion (< 15%) of comatose head-injured patients whose initial computerized tomography (CT) scan was normal or did not show a mass lesion, midline shift, or abnormal basal cisterns develop intracranial hypertension. The aim of the present study was to re-examine this finding against a background of more intensive monitoring and data acquisition. Eight severely head-injured patients with a Glasgow Coma Scale score of 8 or less, whose admission CT scan did not show a mass lesion, midline shift, or effaced basal cisterns, underwent minute-to-minute recordings of arterial blood pressure, intracranial pressure (ICP), and cerebral perfusion pressure (CPP) derived from blood pressure minus ICP. Intracranial hypertension (ICP ≥ 20 mm Hg lasting longer than 5 minutes) was recorded in seven of the eight patients; in five cases the rise was pronounced in terms of both magnitude (ICP ≥ 30 mm Hg) and duration. Reduced CPP (≤ 60 mm Hg lasting longer than 5 minutes) was recorded in five patients. Severely head-injured (comatose) patients whose initial CT scan is normal or does not show a mass lesion, midline shift, or abnormal cisterns nevertheless remain at substantial risk of developing significant secondary cerebral insults due to elevated ICP and reduced CPP. The authors recommend continuous ICP and blood pressure monitoring with derivation of CPP in all comatose head-injured patients.

High-risk mild head injury

1997 ◽  
Vol 87 (2) ◽  
pp. 234-238 ◽  
Author(s):  
John N. K. Hsiang ◽  
Theresa Yeung ◽  
Ashley L. M. Yu ◽  
Wai S. Poon
Keyword(s):  
Head Injury ◽  
High Risk ◽  
Mild Head Injury ◽  
Radiographic Findings ◽  
Content Type ◽  
Head Injured ◽  
Definition Of ◽  
Gcs Score ◽  
Injured Patients ◽  
Fine Print

✓ The generally accepted definition of mild head injury includes Glasgow Coma Scale (GCS) scores of 13 to 15. However, many studies have shown that there is a heterogeneous pathophysiology among patients with GCS scores in this range. The current definition of mild head injury is misleading because patients classified in this category can have severe sequelae. Therefore, a prospective study of 1360 head-injured patients with GCS scores ranging from 13 to 15 who were admitted to the neurosurgery service during 1994 and 1995 was undertaken to modify the current definition of mild head injury. Data regarding patients' age, sex, GCS score, radiographic findings, neurosurgical intervention, and 6-month outcome were collected and analyzed. The results of this study showed that patients with lower GCS scores tended to have suffered more serious injury. There was a statistically significant trend across GCS scores for percentage of patients with positive acute radiographic findings, percentage receiving neurosurgical interventions, and percentage with poor outcome. The presence of postinjury vomiting did not correlate with findings of acute radiographic abnormalities. Based on the results of this study, the authors divided all head-injured patients with GCS scores ranging from 13 to 15 into mild head injury and high-risk mild head injury groups. Mild head injury is defined as a GCS score of 15 without acute radiographic abnormalities, whereas high-risk mild head injury is defined as GCS scores of 13 or 14, or a GCS score of 15 with acute radiographic abnormalities. This more precise definition of mild head injury is simple to use and may help avoid the confusion caused by the current classification.

Efficacy of hyperventilation, blood pressure elevation, and metabolic suppression therapy in controlling intracranial pressure after head injury

2002 ◽  
Vol 97 (5) ◽  
pp. 1045-1053 ◽  
Author(s):  
Matthias Oertel ◽  
Daniel F. Kelly ◽  
Jae Hong Lee ◽  
David L. McArthur ◽  
Thomas C. Glenn ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Blood Flow ◽  
Intracranial Pressure ◽  
Content Type ◽  
Head Injured ◽  
Induced Hypertension ◽  
Metabolic Suppression ◽  
Gcs Score ◽  
Injured Patients ◽  
Fine Print

Object. Hyperventilation therapy, blood pressure augmentation, and metabolic suppression therapy are often used to reduce intracranial pressure (ICP) and improve cerebral perfusion pressure (CPP) in intubated head-injured patients. In this study, as part of routine vasoreactivity testing, these three therapies were assessed in their effectiveness in reducing ICP. Methods. Thirty-three patients with a mean age of 33 ± 13 years and a median Glasgow Coma Scale (GCS) score of 7 underwent a total of 70 vasoreactivity testing sessions from postinjury Days 0 to 13. After an initial 133Xe cerebral blood flow (CBF) assessment, transcranial Doppler ultrasonography recordings of the middle cerebral arteries were obtained to assess blood flow velocity changes resulting from transient hyperventilation (57 studies in 27 patients), phenylephrine-induced hypertension (55 studies in 26 patients), and propofol-induced metabolic suppression (43 studies in 21 patients). Changes in ICP, mean arterial blood pressure (MABP), CPP, PaCO2, and jugular venous oxygen saturation (SjvO2) were recorded. With hyperventilation therapy, patients experienced a mean decrease in PaCO2 from 35 ± 5 to 27 ± 5 mm Hg and in ICP from 20 ± 11 to 13 ± 8 mm Hg (p < 0.001). In no patient who underwent hyperventilation therapy did SjvO2 fall below 55%. With induced hypertension, MABP in patients increased by 14 ± 5 mm Hg and ICP increased from 16 ± 9 to 19 ± 9 mm Hg (p = 0.001). With the aid of metabolic suppression, MABP remained stable and ICP decreased from 20 ± 10 to 16 ± 11 mm Hg (p < 0.001). A decrease in ICP of more than 20% below the baseline value was observed in 77.2, 5.5, and 48.8% of hyperventilation, induced-hypertension, and metabolic suppression tests, respectively (p < 0.001 for all comparisons). Predictors of an effective reduction in ICP included a high PaCO2 for hyperventilation, a high study GCS score for induced hypertension, and a high PaCO2 and a high CBF for metabolic suppression. Conclusions Of the three modalities tested to reduce ICP, hyperventilation therapy was the most consistently effective, metabolic suppression therapy was variably effective, and induced hypertension was generally ineffective and in some instances significantly raised ICP. The results of this study suggest that hyperventilation may be used more aggressively to control ICP in head-injured patients, provided it is performed in conjunction with monitoring of SjvO2.

Efficacy of moderate hypothermia in patients with severe head injury and intracranial hypertension refractory to mild hypothermia

2003 ◽  
Vol 99 (1) ◽  
pp. 47-51 ◽  
Author(s):  
Tadahiko Shiozaki ◽  
Yoshikazu Nakajima ◽  
Mamoru Taneda ◽  
Osamu Tasaki ◽  
Yoshiaki Inoue ◽  
...  
Keyword(s):  
Intracranial Hypertension ◽  
Mild Hypothermia ◽  
Brain Temperature ◽  
Moderate Hypothermia ◽  
Content Type ◽  
Arterial Blood ◽  
Cell Counts ◽  
Head Injured ◽  
Injured Patients ◽  
Fine Print

Object. This study was performed to determine whether moderate hypothermia (31°C) improves clinical outcome in severely head injured patients whose intracranial hypertension cannot be controlled using mild hypothermia (34°C). Methods. Twenty-two consecutive severely head injured patients who fulfilled the following criteria were included in this study: an intracranial pressure (ICP) that remained higher than 40 mm Hg despite the use of mild hypothermia combined with conventional therapies; and a Glasgow Coma Scale score of 8 or less on admission. After the failure of mild hypothermia in combination with conventional therapies; patients were exposed to moderate hypothermia as quickly as possible. As brain temperature was reduced from 34 to 31°C, the volume of intravenous fluid infusion was increased significantly from 1.9 ± 0.9 to 2.6 ± 1.2 mg/kg/hr (p < 0.01), and the dose of dopamine infusion increased significantly from 4.3 ± 3.1 to 8.2 ± 4.4 µg/kg/min (p < 0.01). Nevertheless, mean arterial blood pressure and heart rate decreased significantly from 97.1 ± 13.1 to 85.1 ± 10.5 mm Hg (p < 0.01) and from 92.2 ± 13.8 to 72.2 ± 14.3 beats/minute at (p < 0.01) at 34 and 31°C, respectively. Arterial base excess was significantly aggravated from −3.3 ± 4 at 34°C to −5.6 ± 5.4 mEq/L (at 31°C; p < 0.05). Likewise, serum potassium concentration, white blood cell counts, and platelet counts at 31°C decreased significantly compared with those at 34°C (p < 0.01). In 19 (86%) of 22 patients, elevation of ICP could not be prevented using moderate hypothermia. In the remaining three patients, ICP was maintained below 40 mm Hg by inducing moderate hypothermia; however, these three patients died of multiple organ failure. These results clearly indicate that moderate hypothermia induces complications more severe than those induced by mild hypothermia without improving outcomes. Conclusions. The authors concluded that moderate hypothermia is not effective in improving clinical outcomes in severely head injured patients whose ICP remains higher than 40 mm Hg after treatment with mild hypothermia combined with conventional therapies.

The National Traumatic Coma Data Bank

1983 ◽  
Vol 59 (2) ◽  
pp. 285-288 ◽  
Author(s):  
Lawrence F. Marshall ◽  
Belinda M. Toole ◽  
Sharon A. Bowers
Keyword(s):  
Common Factors ◽  
Data Bank ◽  
Operative Intervention ◽  
Content Type ◽  
Head Injured ◽  
The Common ◽  
Traumatic Coma ◽  
Gcs Score ◽  
Injured Patients ◽  
Fine Print

✓ The records of the first 325 patients entered into the pilot phase of the National Traumatic Coma Data Bank were reviewed. Thirty-four severely head-injured patients who talked prior to deteriorating to a Glasgow Coma Scale (GCS) score of 8 or less were identified. Of those 34 patients, 18 died or were left vegetative and 16 recovered. While there were certain common factors between those who talked and died and those who talked and recovered, there were also significant differences. The common factors between the two groups were the length of time to deterioration or operative intervention (16 versus 18 hours, respectively), and the initial GCS scores (12.6 versus 12.4, respectively). The primary differences between the groups included the mean age, the degree of midline shift seen on computerized tomography (CT), and the presence of subdural hematoma. Those who talked at some point postinjury, but who subsequently died, had a mean age of 50 years. Those who talked, deteriorated, and then recovered were found to have a mean age of 32 years. Seven of the 18 patients who talked and died had a shift of greater than 15 mm on CT, while this degree of shift was demonstrated in only one of 16 patients who talked, deteriorated, and recovered. Subdural hematomas were significantly more common in the “talk and die” group, as was the overall need for operation. Since the overwhelming majority of patients with marked shift on CT have surgical lesions, early operative intervention is strongly recommended in these patients, prior to their inevitable deterioration.

Interhemispheric supratentorial intracranial pressure gradients in head-injured patients: are they clinically important?

1999 ◽  
Vol 90 (1) ◽  
pp. 16-26 ◽  
Author(s):  
Juan Sahuquillo ◽  
Maria-Antonia Poca ◽  
Mercedes Arribas ◽  
Angel Garnacho ◽  
Enrique Rubio
Keyword(s):  
Intracranial Pressure ◽  
Clinical Significance ◽  
Focal Lesion ◽  
Entire Group ◽  
Midline Shift ◽  
Focal Lesions ◽  
Content Type ◽  
Head Injured ◽  
Injured Patients ◽  
Fine Print

Object. It is generally accepted that the intracranial compartment behaves as a unicameral space in which intracranial pressure (ICP) is uniformly distributed. However, this concept has been challenged many times. Although there is general agreement on the existence of craniospinal and suprainfratentorial gradients, the existence of interhemispheric gradients is still a matter of debate. The object of this study was to reexamine the issue of interhemispheric supratentorial ICP gradients in patients with head injuries and the clinical significance of these gradients in their management.Methods. The authors present the results of a prospective study conducted in 50 head-injured patients to determine the clinical significance of supratentorial ICP gradients. In each case a concurrent bilateral frontal intraparenchymatous device was implanted within the 6-hour window after computerized tomography (CT) scanning. According to CT criteria, each patient was categorized into one of three different groups: 1) diffuse lesions, in which no unilaterally measured volumes greater than 25 ml were present and the midline shift was 3 mm or less; 2) Focal A, in which added hemispheric volumes were greater than 25 ml and midline shift was 3 mm or less; and 3) Focal B, in which all patients with a midline shift greater than 3 mm were included. From the results of the entire group the authors were able to distinguish four different patterns of supratentorial ICP. In Pattern I, the intracranial compartment behaved as a true unicameral space with similar mean ICPs and pulse amplitudes in both hemispheres; in Pattern II, different mean ICPs and amplitudes were observed although ICP increases or decreases were congruent; and in Pattern III, patients with different mean ICPs, different ICP amplitudes, and no congruent increases or decreases of ICP were included. All (15 cases) but one patient with a diffuse lesion presented with ICP Pattern I. Fifteen patients with focal lesions showed a Type II pattern, whereas only one patient presented with a Type III pattern. In 10 patients, of whom all but one presented with a focal lesion, transient gradients that disappeared in less than 4 hours were also observed.Conclusions. In many patients with focal lesions, clinically important interhemispheric ICP gradients exist. In this subset, transient gradients that disappear with time are frequently observed and may indicate an increase in the size of the lesion. The clinical relevance of such gradients is discussed and guidelines for adequately monitoring ICP are suggested to optimize head injury management and to avoid suboptimal or even harmful care in patients with mass lesions.

A multicenter prospective randomized controlled trial of the efficacy of mild hypothermia for severely head injured patients with low intracranial pressure

2001 ◽  
Vol 94 (1) ◽  
pp. 50-54 ◽  
Author(s):  
Tadahiko Shiozaki ◽  
Toshiaki Hayakata ◽  
Mamoru Taneda ◽  
Yoshikazu Nakajima ◽  
Naoyuki Hashiguchi ◽  
...  
Keyword(s):  
Randomized Controlled Trial ◽  
Intracranial Pressure ◽  
Mild Hypothermia ◽  
Controlled Trial ◽  
Content Type ◽  
Randomized Controlled ◽  
Prospective Randomized Controlled Trial ◽  
Head Injured ◽  
Injured Patients ◽  
Fine Print

Object. The criteria for the use of mild hypothermia (34°C) in severely head injured patients have not been standardized. A prospective randomized controlled trial was conducted to determine whether mild hypothermia is essential in the treatment of severely head injured patients with low intracranial pressure (ICP). Methods. At 11 medical centers, 91 severely head injured patients with an admission Glasgow Coma Scale score of 8 or less in whom ICP could be maintained below 25 mm Hg by conventional therapies were divided randomly into two groups: the mild hypothermia group (HT group, 45 patients) and the normothermia group (NT group, 46 patients). Patients in the HT group were exposed to mild hypothermia (34°C) for 48 hours, followed by rewarming at 1°C per day for 3 days, whereas patients in the NT group were exposed to normothermia (37°C) for 5 days. The two groups were similar with respect to prognostic factors, and there was no difference in clinical outcome at 3 months postinjury. During treatment, there was a significantly greater use of neuromuscular blocking agents in the HT group (p = 0.011). During the initial 2 weeks postinjury, the incidences of pneumonia, meningitis, leukocytopenia, thrombocytopenia, hypernatremia, hypokalemia, and hyperamylasemia were significantly higher in the HT than in the NT group (p <0.05). Conclusions. Mild hypothermia should not be used for the treatment of severely head injured patients with low ICP because this therapy conveys no advantage over normothermia in such patients.

Cervical spine trauma associated with moderate and severe head injury: incidence, risk factors, and injury characteristics

2002 ◽  
Vol 96 (3) ◽  
pp. 285-291 ◽  
Author(s):  
Langston T. Holly ◽  
Daniel F. Kelly ◽  
George J. Counelis ◽  
Thane Blinman ◽  
David L. McArthur ◽  
...  
Keyword(s):  
Cervical Spine ◽  
Spine Injury ◽  
Cervical Spine Trauma ◽  
Spine Trauma ◽  
Content Type ◽  
Head Injured ◽  
Cervical Injuries ◽  
Gcs Score ◽  
Injured Patients ◽  
Fine Print

Object. Diagnosing and managing cervical spine trauma in head-injured patients is problematic due to an altered level of consciousness in such individuals. The reported incidence of cervical spine trauma in head-injured patients has generally ranged from 4 to 8%. In this retrospective study the authors sought to define the incidence of cervical injury in association with moderate or severe brain injury, emphasizing the identification of high-risk patients. Methods. The study included 447 consecutive moderately (209 cases) or severely (238 cases) head injured patients who underwent evaluation at two Level 1 trauma centers over a 40-month period. Of the 447 patients, 24 (5.4%) suffered a cervical spine injury (17 men and seven women; mean age 39 years; median Glasgow Coma Scale [GCS] score of 6, range 3–14). Of these 24 patients, 14 (58.3%) sustained spinal cord injuries (SCIs), 14 sustained injuries in the occiput—C3 region, and 10 underwent a stabilization procedure. Of the 14 patients with SCIs, nine experienced an early hypotensive and/or hypoxic insult. Regarding the mechanism of injury, cervical injuries occurred in 21 (8.2%) of 256 patients involved in motor vehicle accidents (MVAs), either as passengers or pedestrians, compared with three (1.6%) of 191 patients with non-MVA-associated trauma (p < 0.01). In the subset of 131 MVA passengers, 13 (9.9%) sustained cervical injuries. Patients with an initial GCS score less than or equal to 8 were more likely to sustain a cervical injury than those with a score higher than 8 (odds ratio [OR] 2.77, 95% confidence interval [CI] = 1.11–7.73) and were more likely to sustain a cervical SCI (OR 5.5, 95% CI 1.22–24.85). At 6 months or more postinjury, functional neurological recovery had occurred in nine patients (37.5%) and eight (33.3%) had died. Conclusions. Head-injured patients sustaining MVA-related trauma and those with an initial GCS score less than or equal to 8 are at highest risk for concomitant cervical spine injury. A disproportionate number of these patients sustain high cervical injuries, the majority of which are mechanically unstable and involve an SCI. The development of safer and more rapid means of determining cervical spine integrity should remain a high priority in the care of head-injured patients.

Normal computerized tomography scans in severe head injury

1986 ◽  
Vol 65 (6) ◽  
pp. 784-789 ◽  
Author(s):  
Ramiro D. Lobato ◽  
Rosario Sarabia ◽  
Juan J. Rivas ◽  
Francisco Cordobes ◽  
Servando Castro ◽  
...  
Keyword(s):  
Computerized Tomography ◽  
Ct Scans ◽  
Consecutive Series ◽  
Good Recovery ◽  
Permanent Disability ◽  
Content Type ◽  
Head Injured ◽  
Gcs Score ◽  
Injured Patients ◽  
Fine Print

✓ The authors analyze the clinical course of 46 severely head-injured patients who had completely normal computerized tomography (CT) scans through the immediate posttraumatic period (1 to 7 days after trauma). These patients represent 10.2% of a consecutive series of 448 cases of severe head injuries and two-thirds of the cases showing a normal CT scan on admission (the other one-third of the cases developed new pathology). The usual course in these 46 patients after the initial coma was toward progressive neurological improvement, and 35 patients (76%) achieved a functional level of survival. Nine patients (19.5%) remained comatose for several weeks and developed severe disability. There were two fatalities due to medical complications. The final outcome was more closely related to the duration of coma (the longer the duration the worse the result) than to the initial Glasgow Coma Scale (GCS) score. In fact, 26% of the patients in the lower GCS score ranges (3 to 4 points) made a good recovery and 46% developed moderate disability only. These findings indicate that the grim prognostic significance of deep posttraumatic coma is tempered in the presence of a normal scan. However, the absence of CT abnormalities in severely head-injured patients cannot be equated with a good prognosis because in one-fifth of the cases serious permanent disability develops. Sustained elevation of the intracranial pressure (ICP) was not seen in these patients, indicating that ICP monitoring may be omitted in cases with a normal scan. However, since one-third of the patients with a normal admission scan developed new pathology within the first few days of injury, a strategy for control scanning is recommended. Control CT scans performed more than 6 months after injury showed a significantly higher incidence of brain atrophy in patients developing permanent disability than in those who made a good recovery.

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